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Date:
______________________________
Last Name _____________________________________ Gender _______
Child's First
Name ________________________________
Birth Date ____________ (m/d/y)
Address _____________________________________________ City
__________________
_
Postal Code ___________ Home Phone (_____) _____________ / (_____)______________
E-mail Address _______________________________________________________________
Mother's Name
_______________________________ Occupation _____________________
Business Address ____________________________ Business Phone
(____) _____________
Father's Name _______________________________ Occupation _____________________
Business Address ____________________________ Business Phone (_____)_____________
Marital Status ___________________________________
Siblings Name ___________________________________ Birth Date
_____________ (m/d/y)
Siblings Name ___________________________________ Birth Date
_____________ (m/d/y)
Siblings Name ___________________________________ Birth Date
_____________ (m/d/y)
IN CASE OF EMERGENCY:
Name _______________________ Phone (____) ____________ Relationship ____________
Name _______________________ Phone (____) ____________ Relationship ____________
Pick-up Authorization: __________________________________________________________
____________________________________________________________________________
Allergies or Health Problems of which you wish the school to be aware of ___________________
____________________________________________________________________________
Health Card Number #__________________________
Session
Required:
_______ HALF
DAY _______FULL
DAY
______ Milner Campus (231
Milner Avenue, Scarborough)
______ Pickering Campus
(415 Toynevale Road,
Pickering)
______ Rougemount Campus (365
Kingston Road, Pickering)
______ Rotherglen Campus (403
Kingston Road West Ajax)
______ Village Campus (56 Old Kingston Road, Ajax)
______ Westney Campus (20
O'Brien Court, Ajax)
______ Whitby Campus (200 Byron Street South, Whitby)
Parent Signature ____________________________________
(Parent’s/Guardian’s Signature)
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